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Improving handover of patient care using a new weekend proforma with a focus on ceiling of care.

ABSTRACT: Patient handover is paramount for effective patient care and is often poorly documented or incomplete. North Bristol NHS Trust weekend handover proformas identify medical patients requiring weekend review. Many patients seen during on-call shifts are not handed over. Our aim was to develop Friday ward round proforma sheets for medical patients, to encourage clear documentation of management plans in order to improve handover of important information, particularly ceiling of care decisions. Questionnaires were completed by F1 doctors regarding current handover systems. Baseline data collected by on-call F1s included time of understanding a patient's ceiling of care decision, and difficulty of comprehension of medical notes. Repeat data were collected with novel proformas in situ. Multiple cycles were performed to refine the sheets and target problems arising in their use. Ninety-three percent of F1s wanted improved patient handover, with ceiling of care (87%) and management plans (73%) being the most difficult areas to understand. Time taken to ascertain ceiling of care decisions improved with the introduction of Friday handover proformas; mean time 153 seconds before and 5 seconds after. Clarity and documentation of management plans improved, with 50% improvement in ease of understanding medical notes. Results demonstrate that introducing Friday ward round proformas for medical patients improves communication between weekday and on-call teams, highlights current escalation of care plans, and leads to faster decision-making. Future plans include the introduction of a short educational session to the new F1 doctors and continued progress with introduction into hospital stationary.

SUBMITTER: Akhunbay-Fudge CY

PROVIDER: S-EPMC4949620 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Improving handover of patient care using a new weekend proforma with a focus on ceiling of care.

Akhunbay-Fudge Christopher Yusuf CY Buss Imogen I Ward Abigail A Snead Charlotte C Cole Miranda M Coulter Archie A

BMJ quality improvement reports 20141001 1

Patient handover is paramount for effective patient care and is often poorly documented or incomplete. North Bristol NHS Trust weekend handover proformas identify medical patients requiring weekend review. Many patients seen during on-call shifts are not handed over. Our aim was to develop Friday ward round proforma sheets for medical patients, to encourage clear documentation of management plans in order to improve handover of important information, particularly ceiling of care decisions. Quest ...[more]

PMID: 27493739

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Project description:Clinical Handover remains one of the most perilous procedures in medicine (1). Weekend handover has emerged as a key area of concern with high variability in handover processes across hospitals (1,2,4, 5-10). Studying weekend handover processes within medicine at an acute teaching hospital revealed huge variability in documented content and structure. A total of 12 different pro formas were in use by the medical day-team to handover to the weekend team on-call. A Likert-survey of doctors revealed 93% felt the current handover system needed improvement with 71% stating that it did not ensure patient safety (Chi-squared, p-value <0.001, n=32). Semi-structured interviews of doctors identified common themes including "a lack of consistency in approach" "poor standardization" and "high variability". Seeking to address concerns of standardization, a standardized handover pro forma was developed using Royal College of Physician (RCP) guidelines (2), with direct end-user input. Results following implementation revealed a considerable improvement in documented ceiling of care, urgency of task and team member assignment with 100% uptake of the new proforma at both 4-week and 6-month post-implementation analyses. 88% of doctors surveyed perceived that the new proforma improved patient safety (p<0.01, n=25), with 62% highlighting that it allowed doctors to work more efficiently. Results also revealed that 44% felt further improvements were needed and highlighted electronic solutions and handover training as main priorities. Handover briefing was subsequently incorporated into junior doctor induction and education modules delivered, with good feedback. Following collaboration with key stakeholders and with end-user input, integrated electronic handover software was designed and funding secured. The software is currently under final development. Introducing a standardized handover proforma can be an effective initial step in improving weekend handover. Handover education and end-user involvement are key in improving the process. Electronic handover solutions have been shown to significantly increase the quality of handover and are worth considering (9, 10).

Project description:The GMC states that, 'You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients' medical care…including effective hand-over procedures' [1]. The medical weekend handover system at this tertiary referral centre involved multiple pieces of paper with no clear list of tasks, and no way to identify critically unwell patients. Patients could be missed from the ward round or could be difficult to identify under pressure. The authors felt this process could pose a threat to patient safety so decided to improve it. A questionnaire was distributed to all 11 medical SHOs with 100% response rate. Results showed that 72% thought the process was unstructured, 81% did not think the process was always safe, and 100% thought it could be improved. After discussions with senior medical management and with the approval of the trust audit committee, a new weekend handover proforma was designed, taking into consideration the results and comments from the questionnaire. The new proforma is accessible through a shared drive, which can be accessed by all medical SHOs in the hospital. Each team is able to copy their patients onto the combined ward-based list. There are columns for specific weekend jobs and registrar/SHO reviews. Any potentially unwell patients are highlighted in bold and discussed with the on-call SHO on Friday. All medical SHOs were given a post-implementation questionnaire after the new handover process had been in place for two months. Results of this showed that 100% of SHOs felt an improvement had been made, with 100% stating that the new system was more structured (64% always, 36% most of the time). The SHO's perception of patient safety increased from 81% generally unsafe, to 100% generally safe. The new handover has been well received and supported by the current SHO cohort. Improvements in the structure of handover have been made with perceived improvements in patient safety. Due to the success of the system, the handover proforma is being implemented in the trust's sister hospital.

Project description:In recent years medical handover has been identified as an increasingly important area for hospitals to improve upon, in light of the changes in shift patterns for doctors. Significant changes to weekday handover had recently been successfully introduced at Broomfield hospital. Weekend handover remained a concern, with an electronic and paper system being used simultaneously. Our objectives were to introduce a new electronic handover system for weekend handover at Broomfield Hospital and improve the organisation of the weekend handover meeting to promote patient safety. Doctors involved in weekend handover were surveyed using a questionnaire, to establish insufficiencies in the weekend handover process; where both the electronic ExtraMed system and paper were being used inconsistently. A new weekend handover system was introduced together with a new user-friendly electronic handover database, addressing the identified difficulties in the current system. These changes met the medical handover guidelines set by the Royal College of Physicians. Three months after the launch of the new system, doctors were re-surveyed using a modified questionnaire to assess the impact our changes had made. Before changes were implemented only 12% of doctors surveyed used the electronic system for weekend. Eighty-nine percent found sorting through jobs time consuming and 67% were handed jobs to them meant for a different grade of doctor. Only 41% were aware who to hand weekend discharges to. Subjective assessment of safety was 3.18 out of 5. The electronic system was felt to be time consuming and complicated. After execution of the new weekend handover process, 100% of doctors reported using the electronic system for weekend handover. Only 47% of doctors felt sorting through jobs was time consuming and 89% of doctors were aware who to handover weekend discharges to. Subjective assessment of the safety of weekend handover improved to 3.84 out of 5. Informal interviews on the ward revealed a high degree of satisfaction with the new weekend handover system. In conclusion we found that a structured, well organised weekend handover meeting together with an effective electronic handover system improves the quality of medical weekend handover.

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Improving handover of patient care using a new weekend proforma with a focus on ceiling of care.

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Improving handover of patient care using a new weekend proforma with a focus on ceiling of care.

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